STUDENT APPLICATION FORM 2013

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1 STUDENT APPLICATION FORM 2013, June 16-21, 2013 & June 23-28, 2013 icreate: STEM Design for a Sustainable Future Camp Information: The ExxonMobil Bernard Harris Summer Science Camp (EMBHSSC) is organized to provide activities, experiments, projects, and field experiences for students entering 6 th, 7 th, or 8 th grade in the fall of The camp promotes science, technology, engineering and mathematics (STEM) education and supports historically underserved and underrepresented students with limited opportunities. Students attend the camp free of charge. Students currently in grade 5, 6, or 7 who have an interest in science and mathematics, at least a B average in science and mathematics courses and a passing score on the state s standardized science and mathematics tests are eligible to apply. Immediate family members of the university staff, EMBHSSC camp staff and ExxonMobil employees are not eligible. The EMBHSSC is a two-week, academic, residential camp that emphasizes increasing students mathematics and science knowledge and skills while introducing them to college life and stimulating their interest in science and engineering as a potential career path. Each day, campers will attend classes that include problem solving, research, critical thinking and communication skills incorporated with biology, chemistry, physics, environmental sciences, earth sciences, engineering, technology, design concepts, and field excursions. Certified secondary teachers and university faculty will teach the classes. The camp will be held on the campus of in Charlottesville, Virginia. Students will be housed in a dorm on the university s campus. Camp participants will be selected from the following the state of Virginia, although an emphasis will be placed on recruiting students from the following districts: Brunswick, Danville, Franklin, Hopewell, King and Queen, Martinsville, Northampton, Petersburg, Richmond City, Sussex and Westmoreland Districts. Application Process: Parent/Guardian and student complete the attached student application form (page 2 4). Parent/Guardian or student gives the request for records to the student s school registrar (page 5). Parent/Guardian or student gives a recommendation form to the student s current science teacher (page 6) and current mathematics teacher (page 7). Student writes a 250-word essay. The Student Application Form, essay, records and recommendations are to be sent to ATTN: 2013 EMBHSSC All requested documents are due by the deadline date, April 12, If all requested documents are not received by the deadline date, the application will not be considered. A committee will select campers on May 6, Students may be interviewed prior to being selected, if deemed necessary. You will receive notification on the status of the application no later than May 24, If you have questions or need additional information, call Carolyn Vallas at PLEASE KEEP THIS PAGE FOR YOUR REFERENCE

2 2 STUDENT APPLICATION FORM 2013 APPLICATION DEADLINE IS April 12, 2013 Student Information Please print in blue or black ink or type. Please provide all requested information. Name of Student: Home Address: City State *Zip Code + 4 Ethnicity: of Birth (month/date/year): Gender: Female Male: Adult T-shirt Size: Name of School student is currently attending: Type of School (Check all that apply): Elementary (K-5) Middle (Grades 6-8) K-8 K - 12 Public Parochial Private Charter Current Grade level School District/Parish: Courses Taken during the academic year: Mathematics: Science: Courses Enrolled or plan to enroll in for the academic year: Mathematics: Science: How did you find out about the EMBHSSC? * Go to click on Look up a Zip Code, insert your address for the zip code +4

3 3 Name of Student: School: Current Grade level: List school organizations, any science and/or mathematics activities (Science Fair, math club, after school programs, summer programs, etc.) you have participated in 2011, 2012 and/or Include awards received and offices held. You may attach a separate sheet, if needed. List any community activities and/or community groups that you have been a part of this school year. List any other activity or achievement that you would like to share with the selection committee. A student-written essay must be included with this application. The student essay is to be typed or neatly hand written. If typed, use Arial, Helvetica, or Times New Roman and a font size of 12 points. The essay should not exceed 250 words. In your essay tell the selection committee why you are interested in attending the 2013 ExxonMobil Bernard Harris Summer Science Camp at the. Include in your essay what you hope to gain from this experience, how you think it will help you in the future and why you think you should be selected to attend this camp. Be sure to write your name, current grade level, school and school district at the top of your essay. Signature of Student

4 4 Name of Student: School: Current Grade level: Parent/Guardian Information Instructions: Please complete the following information for at least one custodial parent or guardian, both, if available. Name of Parent or Guardian: Employer: Occupation: Daytime Phone No.: Home Phone No.: Cell Phone No.: Address: Signature of Parent or Guardian Name of Parent or Guardian: Employer: Occupation: Daytime Phone No.: Home Phone No.: Cell Phone No.: Address: Signature of Parent or Guardian Number of People in the Household: Household Yearly Income Level: Under $15,000 $15,001 to $30,000 $30,001 to $45,000 $45,001 to $60,000 $60,001 to $75,000 $75,001 - $90,000

5 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP 2013 at the 5 REQUEST FOR RECORDS You or your child must give this form to the registrar at his/her school. A parent or guardian must sign this request so that the registrar can release the records. Dear Registrar: Please forward a copy of official records for this student (grades and standardized test scores) and this form by April 12, 2013, to: ATTN: 2013 EMBHSSC The records must include a copy of the most recent grades/report card and standardized test scores. This form must accompany the records. I hereby grant permission to the release of the information that this form is requesting on my child. Signature of Parent or Guardian Name of Student (please print) Student ID Number Signature of Student School Grade of Birth Homeroom Teacher Does this child receive FREE or REDUCED lunch? Yes No If yes, which? Free Lunch Reduced Lunch

6 6 Name of Teacher Recommendation from Current SCIENCE Teacher For a Student applying for The ExxonMobil Bernard Harris Summer Science Camp (EMBHSSC) 2013 at the Directions to teacher: The student who has given you this form is applying to attend the EMBHSSC this summer. You have taught this student, so you can tell if she/he is a good candidate for this two-week residential program designed to change the lives of students with limited opportunities. Complete the chart below and write a letter of recommendation for this student. Place completed form and letter of recommendation into an envelope, seal it, and write your name across the sealed flap, so that your comments will be private. Please return the sealed envelope to the student as soon as possible or mail to be received by the deadline date of April 12, ATTN: 2013 EMBHSSC (Refer to under programs for Summer Science Camp description.) Name of student Course taken with this teacher: Subject Year Please put an X in the appropriate column for each of the following statements: Very Much Often Sometimes Rarely Never This student was eager to learn. This student cared about other students. This student was late to class. This student skipped classes. This student turned in homework and projects on time. This student participated in class, group and handson activities. This student worked independently and as a team member. This student was an asset to the class. This student participated in co-curricular activities (science fair, science club, etc.). Circle the best answer to the following question: Would you like to teach this student in another class? Yes, definitely Maybe Definitely not Below please write 2-3 sentences about the student that makes this student stand out from the rest. If you prefer, include all of your comments in the letter of recommendation that includes outstanding school achievements, any concerns you would like to share, and the qualities this student possess that makes him/her stand out from the rest. Your comments will be especially useful in the selection process. Thank you.

7 7 Name of Teacher Recommendation from Current MATHEMATICS Teacher For a Student applying for The ExxonMobil Bernard Harris Summer Science Camp (EMBHSSC) 2013 at the Directions to teacher: The student who has given you this form is applying to attend the EMBHSSC this summer. You have taught this student, so you can tell if she/he is a good candidate for this two-week residential program designed to change the lives of students with limited opportunities. Complete the chart below and write a letter of recommendation for this student. Place completed form and letter of recommendation into an envelope, seal it, and write your name across the sealed flap, so that your comments will be private. Please return the sealed envelope to the student as soon as possible or mail to be received by the deadline date of April 12, ATTN: 2013 EMBHSSC (Refer to under programs for Summer Science Camp description.) Name of student Course taken with this teacher: Subject Year Please put an X in the appropriate column for each of the following statements: Very Much Often Sometimes Rarely Never This student was eager to learn. This student cared about other students. This student was late to class. This student skipped classes. This student turned in homework and projects on time. This student participated in class, group and handson activities. This student worked independently and as a team member. This student was an asset to the class. This student participated in co-curricular activities (science fair, science club, etc.). Circle the best answer to the following question: Would you like to teach this student in another class? Yes, definitely Maybe Definitely not Below please write 2-3 sentences about the student that makes this student stand out from the rest. If you prefer, include all of your comments in the letter of recommendation that includes outstanding school achievements, any concerns you would like to share, and the qualities this student possess that makes him/her stand out from the rest. Your comments will be especially useful in the selection process. Thank you.

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